Transcript Depressed Mental Status - the UA Department of Pediatrics

Acutely Depressed
Mental Status in Children
National Pediatric Nighttime Curriculum
Written by Terry Platchek, MD
Lucile Packard Children’s Hospital, Stanford University
Objectives
Be able to recognize children with acutely
depressed mental status
 Know the major causes of acutely
depressed mental status in children
 Initiate the workup for depressed mental
status in children
 Initiate management of depressed mental
status in children

Definitions

Coma:

Unarousable unresponsiveness
 The most profound state of depressed mental status

Stupor, Lethargy, Difficult to Arouse, Obtunded:

All of these terms are imprecise and describe a decreased level of
consciousness
 May be marked by absence of spontaneous movement and diminished
responsiveness to stimulation
 Awareness is generally impaired before arousal

Brain Death (1-18 y.o.):

Criteria include coma, apnea, and absent brainstem reflexes
 Brain death specifically implies no opportunity for recovery
Physiology


Arousal: The physiology of arousal is
dependent on the reticular activating
system (RAS). The RAS is a poorly
localized network of cells in the
brainstem with projections to the
thalamus, hypothalamus and cortex.
From C.J. Long, Visual Slide
Presentation
Awareness: Awareness is mediated
by the cerebral cortex in widely distributed neuronal
networks. Awareness is the product of cortical function that
resides within both hemispheres and then projects down to
the thalamus and then out, for either motor or sensory
functions.
Etiology of Non-Traumatic Pediatric Coma from UK
Prospective Study
From: C P Wong, R J Forsyth, T
P Kelly, J A Eyre. Incidence,
aetiology, and outcome of
non-traumatic coma: a population
based study. Arch Dis Child
2001;84:193–199
Workup
Depressed mental status is a medical
emergency with a broad differential
 Determination of etiology is essential for
optimal treatment
 Workup requires a systematic approach

Etiology of Depressed Mental Status (from Berger et al)
Nonstructural, Symmetrical
Toxins

Lead,Thallium, Mushrooms, Cyanide, Methanol,
Ethylene glycol, Carbon Monoxide
Structural, Symmetrical
Supratentorial

Drugs

Sedatives, Barbiturates*, Hypnotics, Tranquilizers,
Bromides, Alcohol, Opiates, Paraldehyde, Salicylate,
Psychotropics, Anticholinergics, Amphetamines,
Lithium, Phencylidine, MAOi’s
Infratentorial

Metabolic

Hypoxia, Hypercapnia, Hypernatremia*,
Hypoglycemia*,Hypergylcemic nonketotic coma,
Diabetic ketoacidosis, Lactic acidosis, Hypercalcemia,
Hypocalcemia, Hypermagnesemia, Hyperthermia,
Hypothermia, Reye's encephalopathy,
Aminoacidemia, Wernicke's encephalopathy,
Porphyria, Hepatic encephalopathy*, Uremia, Dialysis
encephalopathy, Addisonian crisis, Hypothyroidism

Sepsis, Bacterial meningitis, Viral encephalitis,
Postinfectious encephalomyelitis, Syphilis, Typhoid
fever, Malaria, Waterhouse-Friderichsen syndrome
Other

Postictal* , Diffuse ischemia (MI, heart failure,
arrhythmia), Hypotension, Fat embolism*,
Hypertensive encephalopathy, Hypothyroidism,
Nonconvulsive status epilepticus, Heat stroke
Basilar occlusion*, Midline brainstem tumor , Pontine
hemorrhage*, Central pontine myelinolysis
Structural, Asymetrical
Supratentorial
Infections

Bilateral internal carotid occlusion, Bilateral anterior
cerebral artery occlusion, Sagittal sinus thrombosis,
Subarachnoid hemorrhage ,Thalamic hemorrhage*,
Trauma-contusion, concussion*, Hydrocephalus
TTP•, DIC, Nonbacterial thrombotic endocarditis,
Subacute bacterial endocarditis, Fat emboli, Unilateral
hemispheric mass (tumor, abscess, bleed) with
herniation, Subdural hemorrhage, bilateral
Intracerebral bleed, Pituitary apoplexy•, Massive or
bilateral supratentorial infarction, Multifocal
leukoencephalopathy, Creutzfeldt-Jakob disease
Adrenal leukodystrophy, Cerebral vasculitis, Subdural
empyema, Thrombophlebitis•, Multiple sclerosis,
Leukoencephalopathy from chemotherapy, Acute
disseminated encephalomyelitis (ADEM)
Infratentorial

Brainstem infarction, Brainstem hemorrhage,
Brainstem thrombencephalitis
* Relatively common asymmetrical presentation.
• Relatively symmetrical presentation
Focused History
AMPLE History
A:
Allergy/Airway
M: Medications
P:
Past medical history
L:
Last meal
E:
Event - What happened?
 Rapid
or Gradual Onset?
 Preceding Headache or Neurologic Symptoms?
 Ingestions?
 Vague or inconsistent history from caregiver is
suspicious for non-accidental trauma.
Focused Physical Exam (suggested by Michelson et al.)



ABC’s (including cardio-respiratory exam)
Vitals
Neurologic examination




Brief and to the point
Differentiate structural from non structural causes
Assess: Level of consciousness/responsiveness, Motor responses,
Brainstem reflexes
Meningismus / Nuchal Rigidity
Brudzinski’s sign - Involuntary hip & knee flexion with forced neck flexion
 Kernig’s sign - involuntary knee flexion with forced flexion of the hip


Fundoscopy

Papilledema suggests increased ICP of more than several hours duration.
 Retinal hemorrhages in an infant are a sign of non-accidental trauma

Skin

Bruising may suggest trauma, rashes may suggest infection
Pediatric Glasgow Coma Scale
Infant < 1 yr
Child 1-4 yrs
> 4 years
EYES
4
Open
Open
Open
3
To voice
To voice
To voice
2
To pain
To pain
To pain
1
No response
No response
No response
VERBAL
5
Coos, babbles
Oriented, speaks, interacts, social
Oriented and Alert
4
Irritable cry, consolable
Confused speech, disoriented,
consolable
Disoriented
3
Cries persistently to pain
Inappropriate words, inconsolable
Nonsensical speech
2
Moans to pain
Incomprehensible, agitated
Moans, unintelligible
1
No response
No response
No response
MOTOR
6
Normal spontaneous
movement
Normal spontaneous movement
Follows commands
5
Withdraws to touch
Localizes pain
Localizes pain
4
Withdraws to pain
Withdraws to pain
Withdraws to pain
3
Decorticate flexion
Decorticate flexion
Decorticate flexion
2
Decerebrate extension
Decerebrate extension
Decerebrate extension
1
No response
No response
No response
Management (adapted from Thompson and Williams)

ABCs / PALS






Stabilize C-Spine if indicated
Intubate for GCS ≤ 8
D10% - 2.5 mL/kg IV
Lorazepam (0.1 mg/kg) for
clinical seizures
Antidote or reversal agent if
known/suspected ingestion
For Infection


Ceftriaxone, Vancomycin
Acyclovir

For increased ICP


Mannitol 0.5-1g/kg
For non-convulsive status
epilepticus

Lorazepam or Fosphenytoin
Treat Underlying
Cause
Labs (adapted from Michelson et al.)

If cause for depressed mental status is not readily
apparent send:
Bedside blood glucose
Electrolytes with Ca, Mg
BUN, creatinine
Transaminases

Urine drug screen
Complete blood count
Blood culture
ABG/VBG, ammonia
If suspected metabolic abnormality send:
UA, urine ketones, plasma amino acids, urine organic acids,
plasma free fatty acids, carnitine profile, lactate, pyruvate
Diagnostic Studies

CT is the initial neuro-imaging test of choice.
 MRI
with DWI can be considered as an adjunct.

LP after increased ICP has been ruled out

EEG to rule out nonconvulsive status epilepticus
should be performed in children with depressed
mental status where etiology remains elusive.
Case 1
A 16 year old girl is brought in unconscious by
friends from a party. Physical exam notes the
smell of alcohol, tachycardia to 178, fever to 39.8,
diaphoresis and BP 185/107. You are called to
consult in the ED. What is the most likely etiology
of her altered mental status?
MDMA (ecstasy)/Amphetamine intoxication
What if the same patient has absent sweating and
dilated pupils?
Anticholenergic Intoxication
Case 2
A 3 year old boy with a past medical history
of OTC deficiency is admitted with cellulitis.
He is found unresponsive in the child life
room. As the pediatrics resident, you are
called for urgent evaluation.
Please provide a DDx and workup.
DDx includes hyperammonemia, hypoglycemia, sepsis,
ingestion, trauma, or sub-clinical seizures.
Workup should include a focused physical exam,
chemistries, free flowing ammonia, glucose, CBC, cultures
and possible ABG. Evidence of trauma should prompt an
immediate head CT.
References
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Berger, Joseph R. Clinical Approach to Stupor and Coma. In:
Neurology in Clinical Practice: Principles of diagnosis and
Management, 4th ed, Bradley, WG, Daroff, RB, Fenichel, GM,
Jankovic, J (Eds), Butterworth Heinmann, Philadelphia, PA 2004.
p.46.
C P Wong, R J Forsyth, T P Kelly, J A Eyre. Incidence, aetiology,
and outcome of non-traumatic coma: a population based study.
Arch Dis Child 2001;84:193–199
Michelson D, Thompson L, Williams E. Evaluation of stupor and
coma in children. UpToDate. 2006.
Simpson D, Reilly P. Pediatric coma scale. Lancet 1982; 2:450.
Teasdale G, Jennett B. Assessment of coma and impaired
consciousness. A practical scale. Lancet 1974,2:81-84 [Glasgow
Coma Scale]
Thompson L, Williams E. Treatment and Prognosis of Coma in
Children. UpToDate. 2010.